ASSESSING THE NEEDS OF NNP PRECEPTORS Assessing the Needs of NNP Preceptors DNP ...

67 Pages·2016·0.71 MB·English

by  Keels, Erin

Running head: ASSESSING THE NEEDS OF NNP PRECEPTORS 1

Assessing the Needs of NNP Preceptors

DNP Final Project

Presented in Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree in
the Graduate School of the Ohio State University

By

Erin L. Keels, MS, APRN, NNP-BC

Graduate Program in Nursing

The Ohio State University
2016

DNP Project Committee:
Deborah K. Steward, PhD, RN, Advisor
Tondi Harrison, PhD, RN, FAAN
Laureen Smith, PhD, RN, FAAN
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Abstract
Neonatal Nurse Practitioners (NNPs) provide high quality, safe and effective care to high risk
neonates, and are valuable members of collaborative care team models in Neonatal Intensive
Care Units (NICU) across the United States. Limited access to NNP preceptors for NNP students
has been cited as a contributing factor to the NNP workforce shortage. This project, in the form
of a needs assessment, aimed to better understand the challenges and needs, in terms of essential
items, processes or supports, from the perspective of NNP preceptors, related to NNP students
preceptorship. The 13 item needs assessment was conducted through a one time, cross sectional,
electronic survey of NNPs who were members of NANN, who currently practiced in a NICU in
the U.S. and had precepted an NNP student between the years of 2013-2016. Survey respondents
(n=77) indicated that they need to have 1) lighter workloads, including smaller patient
assignments and better preparation of students for clinical rotations; 2) meaningful rewards with
consideration of monetary compensation for precepting; and 3) improved support and
preparation for the role of precepting, including enhanced faculty collaboration and
communication, formal preparation for the role of precepting, and defined structures and
processes for precepting activities. While workload issues are difficult to address during the
current national NNP workforce shortage, consideration for lighter workloads when precepting
could be helpful, as would meaningful non-monetary and monetary rewards and recognition for
precepting. Findings from this survey indicate that, with input from faculty, NNPs should
develop and implement formal processes to guide clinical site preceptorships. Guidelines should
include plans for regular communication and collaboration with faculty, formal preparation for
and ongoing evaluation of the role of NNP preceptor, and definitive infrastructure to support
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precepting activities. Understanding and addressing these needs could improve access to clinical
preceptorships for NNP students and decrease the NNP workforce gap.
Key Words: neonatal nurse practitioner, neonatal nurse practitioner preceptor, neonatal
nurse practitioner student, precepting.
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Chapter 1: Nature of the Project
Background and Problem
Neonatal Nurse Practitioners (NNPs) are Advanced Practice Registered Nurses (APRNs)
educated at the graduate or doctoral level and nationally board certified to care for high risk
neonates across the care continuum from birth to the age of two years (National Association of
Neonatal Nurses [NANN], 2014b). As a member of collaborative clinical teams, NNPs provide
safe, effective and high-quality neonatal care in a variety of settings, including neonatal intensive
care units (NICUs), transport vehicles, delivery rooms, well baby nurseries, and outpatient
healthcare settings (Cusson, Buss-Frank, Flanagan, Miller, Zukowsky, & Rasmussen, 2008;
NANN, 2014b). The quality, safety, and cost effectiveness of care to high risk infants by NNPs
is equivalent or greater than that provided by pediatric resident housestaff and physician
assistants (Bosque, 2015; Carzoli, Martinez-Cruz, Cuevas, Murphy, & Chiu, 1994; Fry, 2011;
Karlowicz & McMurray, 2000; Mitchell-DiCenso et al., 1996; Sheldon, Corff, McCann, &
Kenner, 2015). Consequently, the role of the NNP in the care of neonatal patients has been
endorsed by the American Academy of Pediatrics (American Academy of Pediatrics [AAP],
2009) and in the Guidelines for Perinatal Care (AAP & American College of Obstetrics and
Gynecology [ACOG], 2012).
Currently, the demand for NNPs outpaces the supply, and a national NNP workforce
shortage exists (Meier & Staebler, 2014). Cited reasons for the shortage include decreased
enrollment in NNP educational programs, limited access to clinical sites and preceptors, loss of
practicing NNPs to retirement or decreased work hours, increased bed capacity in NICUs in the
United States (U.S.), and decreased pediatric resident duty hours (Meier & Staebler, 2014). The
shortage of NNPs is felt at the bedside, where NNPs may have burdensome workloads, creating
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frustration, burnout and potential safety hazards (NANN, 2013) further challenging NNP
recruiting and retention endeavors.

Ethical Principles
Important ethical principles to consider relative to the NNP workforce shortage and
limited access to NNP preceptors are beneficence (the obligation to do good), nonmaleficence
(the obligation to avoid harm), justice (the fair allocation of resources), and equity (the freedom
from bias) (Fry, Veach, & Taylor, 2011). Consistent with the Code of Ethics from both the
American Nurses Association (American Nurses Association [ANA], 2015) and the National
Association of Neonatal Nurses (NANN) (NANN, n.d.), NNP preceptors and NNP students
(along with other healthcare providers) seek to “do good” and avoid harm when caring for ill,
preterm and high risk infants. Further, the act of teaching and mentoring an NNP student to
become competent in the role in order to provide safe, effective and high quality care is good and
beneficial for patients, families, organizations, and the professionals involved. However, the
NNP workforce shortage, coupled with decreased pediatric resident duty hours, has caused many
NNPs to care for higher than recommended patient care loads (Meier & Staebler, 2014), which
could negatively impact the quality and safety of patient care, and could violate the ethical
principle of nonmaleficence. Moreover, precepting an NNP student while carrying a difficult
workload could further strain the NNP preceptor’s ability to provide safe and effective care,
potentially placing the patient at risk, also violating the rule of nonmaleficence. Furthermore, the
NNP workforce shortage, combined with geographic locations of academic centers and
competitive compensation markets, have led to uneven distribution of NNPs across the United
States (Freed, Dunham, Moote, Lamarand, & American Board of Pediatrics Research Advisory
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Committee, 2010; Meier & Staebler, 2014). This unbalanced dispersal of the NNP workforce
causes varying compositions of neonatal care teams (Meier & Staebler, 2014; Kenner, Corff,
McCann, & Sheldon, 2015) and variable access to NNP preceptorships in some areas of the
country, violating the principles of justice and equity (Fry, Veach, & Taylor, 2011).
Efforts to address the NNP workforce gap are underway at the national level through
NANN and the National Association of Neonatal Nurse Practitioners (NANNP) in order to
continue to provide high quality, safe and effective care to high risk infants in NICUs and
delivery rooms around the U.S. (NANN, 2014a). In response, experts have called for improved
access to NNP preceptorships as one strategy to close the gap in workforce (Freed et. al., 2010;
NANN, 2013; NANN, 2014a; NANN, 2014b; Meier & Staebler, 2014).
Purpose of the Project
There is evidence to support the valuable contributions of NNPs’ care to neonatal patients
and families. Unfortunately, there is also evidence to suggest that the current workforce shortage
threatens that care. This DNP final project addressed the impact of limited access to NNP
preceptors to the NNP workforce shortage. Building off work that has been previously published
related to challenges and needs of nurse and Nurse Practitioner (NP) preceptors, including NNPs,
this project aimed to assess the needs of NNP preceptors related to the preceptorship of NNP
students. In this context, “needs” referred to the essential items, resources or supports that
facilitate effective preceptorship arrangements between the NNP preceptor and student. From
this, evidence based strategies could be developed to mitigate these challenges, and improve the
availability and accessibility of NNP preceptors, and/or lead to policy/process changes at the
organization, state and national levels. In turn, these changes may help to improve access to
preceptors for student NNPs and help decrease the shortage of practicing NNPs.
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Clinical Practice Problem Statement
While there are many real and perceived challenges to NNP preceptorships, there is a
lack of evidence describing what NNP preceptors need in order to engage in effective preceptor
arrangements. Therefore, the clinical question for this project was: “When Neonatal Nurse
Practitioners precept neonatal nurse practitioner students, what are the needs”?
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Chapter 2: Review of the Literature
Preceptorships
In general, preceptorship describes the short term, cognitive, and apprenticeship-like
relationship between a student and an experienced professional where theoretical knowledge is
translated to clinical practice, offering the preceptee the opportunity to gain competence and
confidence (Smedley, 2008). For nurse practitioners and other professionals, participation in a
preceptorship can satisfy the preceptor’s professional obligations and contribute to personal and
professional growth (Gibson & Hauri, 2000), as well as prepare future generations to continue
the profession (Newland, 2014). For optimal learning and growth to occur, it is important to
assure that the fit in terms of expectations, personality, and learning styles between preceptor and
preceptee is appropriate and the necessary provisions are in place, such as faculty support and
preceptor preparation (Gibson & Hauri, 2000; Lyon & Peach, 2001; Smedley, 2008), along with
conducive clinical practice site environments (Lyon & Peach, 2001; Henderson, Fox, & Malko-
Nyhan, 2006). Additional factors to consider and address in order to optimize precepting
arrangements for NP students include health care system credentialing of the preceptor and/or
the student, state APRN scope of practice rules, state education regulations, professional
organization education standards and competencies, legal liability, and billing and
reimbursement issues (Amella et al., 2001; Link, 2009).
In addition to the above, NNP student preceptorship should proceed according to the
Education Standards and Curriculum Guidelines for Neonatal Nurse Practitioner Programs
(NANN, 2014c). NNP students must obtain 200 hours of didactic instruction and acquire 600 to
720 directly supervised clinical preceptorship hours spread across delivery rooms and level II, III
and IV NICUs. NNP preceptors may be board certified (or eligible) physicians or masters or
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doctorally prepared, board certified NNPs. The preceptorship experience should encompass a
wide variety of patient populations and disease processes to manage, as well as opportunities to
build competence in communication, collaboration, transitions of care and family centered care
strategies. According to the Education Standards and Curriculum Guidelines, NNP preceptors
must have completed at least one year of fulltime practice in the NNP role and clinical setting,
should not precept more than two NNP students at one time, must be oriented to the NNP
Education Standards and Curriculum Guidelines, and must be annually evaluated on his or her
effectiveness as a preceptor. It is recommended that one primary preceptor be responsible for the
student during the clinical site preceptorship. This primary preceptor ensures that the preceptor
responsibilities are met. These include socialization into the setting, scheduling, obtaining the
requisite clinical learning opportunities, and evaluation of the student’s performance (NANN,
2014c).
Along with the requirements that are necessary for admission into individual academic
institutions, NNP students must have attained the equivalent of 2 years of fulltime clinical
practice (within the last 5 years) as a registered nurse (RN) in the care of critically ill neonates or
infants in critical care inpatient settings prior to the commencement of clinical site precepted
experiences (NANN, 2014c). This requisite clinical experience is considered a proxy for
evidence of critical thinking skills, and is thought to be necessary for successful transition to the
NNP role.
Impact to NNP Preceptors
The impact and challenges of NNP student preceptorship to NNP preceptors is not well
understood. Studies of other NP preceptors find that, while they were satisfied with the preceptor
role, they cited issues of high work load, poor efficiency, concerns around legal liability when
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billing for services, precepting “burnout”, inadequate faculty communication and collaboration,
poor preparation or “fit” of the student, lack of physical space, lack of additional compensation
for precepting, and obligations to precept other professional students as challenges to precepting
(Lyon & Peach, 2001; Logan, Kovacs, & Barry, 2015).
While the NNP roles of preceptor, coach and mentor are clearly delineated in the NNP
Core Competencies (NANNP, 2014), access to NNP preceptorship can be a challenge for more
than 230 NNP students each year, despite the fact that there are about 5200 practicing NNPs in
the U.S.(Bellini, 2014; Meier & Staebler, 2014). In order to more fully understand recruitment of
and support for NNP preceptors, a survey was conducted of all NNP Graduate Program Directors
in the U. S. (N=44) and NNP preceptors (N=121) who were associated with a single university
graduate NNP program (Wilson et al., 2009). The NNP preceptors who responded (n=58) to the
survey were NNPs, neonatologists and pediatricians. They were asked to indicate to what extent
they agreed on a scale of 1 to 5, with 1=strongly agreed and 5=strongly disagreed, that a list of
supportive activities drafted by the study’s authors would be helpful to assist in their precepting
activities. The results ranged from an average score of 1.7 for “providing preceptors with access
to free continuing education modules online” to an average score of 2.6 for “offering an on-site
workshop for preceptors”, signifying that the preceptors agreed that those supportive activities
would be helpful. Also, the preceptors entered additional free text comments to identify other
strategies they thought would be helpful to support precepting activities. These comments
included “frequent communication with faculty”, “monetary compensation”, and “more NICU
clinical experience before students enter the NNP program.” Interestingly, the list of supportive
activities for NNP preceptors that was drafted by the study authors included items that were
related to rewards (faculty appointment or free continuing education opportunity) and preceptor